LWC Media Credential Application
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Name (First & Last) *
Media Outlet/Organization *
Email Address *
Mobile Phone/Business Phone *
Address, City, State, Zip *
Type of Organization *
Circulation/Viewership *
Name of Assigning Editor/Publisher/Producer *
Editor/Publisher/Producer Phone *
Editor/Publisher/Producer Email *
Medium *
Description of Assignment(s)
Intended Date of Publication
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